FOLIOJacksonville was once again held up as a national scourge last week when media from The Palm Beach Post to The Huffington Post, The Atlantic, The Guardian and even Wonkette reported that the city is the epicenter of the worst tuberculosis outbreak to strike the U.S. in decades. Gov. Rick Scott was also faulted for closing the state’s only tuberculosis hospital, and the state Department of Health was accused of keeping the outbreak a secret from the public.
The Palm Beach Post first reported on July 8 that an investigation by the U.S. Centers for Disease Control into TB cases in Jacksonville, which was released on April 5, found an outbreak of epidemic proportions. The number of people contaminated by a strain of TB, concentrated in the city’s homeless population, had grown rapidly over the past two years, resulting in the most extensive outbreak the CDC has investigated in the past 20 years.
This wasn’t unexpected news for a former employee of the Duval County Health Department. Kevin Davis said the Health Department knew two years ago it had a growing TB problem in the city’s homeless shelters, and failed to mobilize.
Davis said the response was so inept that in December 2010, the Health Department even lost track for a month of a homeless, mentally ill man with active TB, as Folio Weekly reported in “Going Viral” (Dec. 6, 2011).
Though one man with active TB in a city of 1.4 million might not seem like a big deal, Davis pointed out that during that month the man was missing, he may have exposed hundreds of other people — in homeless camps, soup kitchens and shelters — to the disease.
“If you don’t track people down and treat them, guess what?” Davis said. “It spreads.”
Davis worked for the Duval County Health Department for 20 years, leading the county’s response to TB cases from 2005-’10. When another employee was given those duties in October 2010, Davis found a lot to fault in the handling of TB cases. He said he was fired in April 2011 because he criticized how his replacement managed the cases, and he filed a whistleblower complaint with the state. The Health Department contends Davis was fired because he lied about driving the TB unit van. There were 28 undocumented miles on the van’s odometer.
The TB strain FL0046 was first identified in Jacksonville in 2004. But it didn’t gain a foothold until 2008, when an outbreak among mentally ill patients at Golden Retreat Shelter Care Center was traced to the strain. The 12 active cases documented in that outbreak began with a schizophrenic homeless man who’d showed symptoms for months before he was diagnosed. Davis helped the CDC coordinate a campaign to bring the outbreak under control, and he won state recognition for his work.
Although the Golden Retreat outbreak was contained, FL0046 continued to spread among the city’s homeless population. The number of TB cases in Duval County declined from 89 cases in 2009 to 71 in ’11, but the percentage of patients infected with FL0046 in that time increased to 96 percent of all cases. There were also 13 deaths of patients diagnosed with the illness. The CDC estimates that in the past two years, more than 3,000 people have been exposed to someone contagious through Jacksonville homeless shelters.
Davis said he blames the Health Department because the agency had indications of an outbreak in October 2010. Two hospitals that month reported active cases of TB that traced back to two homeless shelters. Testing at the City Rescue Mission documented a startling increase in positive results for TB exposure from 22 percent on Oct. 1 to 77 percent a few weeks later. Davis said a rate of positive tests greater than 15 percent indicates a problem.
And then in December 2010, the Health Department may have actually aided the spread of FL0046, when it lost track for a month of a homeless man with active TB.
Memorial Hospital notified the Health Department it had a second active TB case on Dec. 21, 2010. But no one from the Health Department followed through; no one met with the patient or set up a treatment program. That would have been Davis’ job, but Cynthia Benjamin now had that responsibility. An active case of TB requires at least six months of treatment, with four antibiotics daily, to phase it into remission. Treatment is so important, the Duval County Health Department, like others in the state, will go to patients to administer their daily medications.
Memorial treated the man for a month, long enough to put the disease into temporary remission. In January 2011, the hospital notified the Health Department that it had discharged him. When the man resurfaced at City Rescue Mission a month later, in February 2011, his tuberculosis was active again and he was highly contagious. That created the perfect breeding ground for advancing FL0046, Davis said.
“He wandered the street for a month,” Davis said. “He would be going from shelter to shelter to shelter, sleeping in a place with 200 to 300 other people every night. Each time he went to another shelter, he exposed another 200 to 300 people.”
The Palm Beach Post reported that the CDC began investigating Duval County cases after the Health Department contacted the agency in February 2012. The newspaper noted that just nine days after the CDC issued its report on April 5, documenting the alarming outbreak, Gov. Scott closed the A.G. Holley State Hospital in Lantana. If state leaders had understood the extent of TB crisis in Jacksonville, the Post implied, the hospital might have been saved. A.G. Holley is the only tuberculosis hospital in the state. It has played an important role in treating TB, because if a patient failed to adhere to the treatment regimen elsewhere, he could be court-ordered into treatment at A.G. Holley.
To assure Jacksonville it had begun a full-frontal assault on the illness in the middle of the media storm, the Duval County Health Department explained its plan of attack. After the April CDC report, the Health Department organized the Jacksonville Community Tuberculosis Coalition, a group made up of representatives from the mayor’s office, Jacksonville Sheriff’s Office, area homeless service organizations and health professionals, to plan the best way to stop the spread of tuberculosis. The plan included increased periodic testing of clients at agencies that serve the homeless, broader testing of those entering shelters, a database to track people tested for the disease and outreach testing efforts that included going to homeless camps and other places where homeless people congregate.
That’s the kind of response that might have contained the disease two years ago, lessened the number of people exposed (in the thousands) to the disease and maybe even saved lives.
Instead, the Health Department did a mass testing of 212 people after it found the Memorial patient in February 2011. He was the only active case, but 56 others tested positive for exposure. Some of those might someday develop active TB. But all of the other testing at homeless shelters throughout 2011 were only small samplings of people. Only nine were tested at the Salvation Army in June, and six of them didn’t return to complete the test. When this limited testing showed only a handful of positive cases, it may have seemed like the problem was under control.
The investigation launched by the CDC, just two months after Folio Weekly’s story, shows the Health Department failed to understand its own data.
“They knew,” Kevin Davis said. “They had the road map [where to find the disease] in 2008 and in 2010. And they did nothing.”
Susan Cooper E
sceastman@folioweekly.c
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